Psychotherapy Training in Residency Programs in Demand and in Peril

Psychotherapy Training in Residency Programs in Demand and in Peril

Psychiatry residents want and need solid training in psychotherapy in order to best serve their patients and to remain competitive in the mental health marketplace, concluded a March conference sponsored by the American Psychiatric Association's Commission on Psychotherapy by Psychiatrists (COPP). The event, entitled "Integration and Specificity in Psychotherapy Education," drew 120 training directors, residents and faculty from around the country, and represented approximately 40% of U.S. residency training programs.

According to COPP chair Norman A. Clemens, M.D., while many residency programs offer exposure to cognitive-behavioral, psychodynamic and supportive therapies, residents are not adequately prepared to competently use them to treat patients. In a recent article, Clemens added that exposure to family therapy, group therapy and interpersonal therapy is even rarer, and that there is significant variability in the quality and intensity of psychotherapy training among residency training programs (Clemens, 1999).

COPP vice chair Glen Gabbard, M.D., Bessie Walker Callaway Distinguished Professor at the Menninger School of Psychiatry and Mental Health Sciences, is similarly concerned and feels that there is an ongoing lack of emphasis on the integration of biological and psychosocial therapies in training programs (Gabbard, 1997). "Patients should be thought of both in psychological and biologic terms to avoid fragmenting the patient and the treatment," wrote Gabbard. "Moreover, psychodynamic psychiatry should not be regarded as anti-biologic. Psychodynamic and biological approaches generally work synergistically to enhance treatment outcomes and preserve the patient's holistic experience."

Gabbard believes that managed care has encouraged this dichotomy through the frequent practice of splitting a patient's treatment between a psychiatrist for pharmacotherapeutic interventions and nonmedical mental health care professionals for talk therapy. Moreover, Gabbard told Psychiatric Times, the advent of effective psychopharmacological treatments and growing advances in genetic research and imaging technologies have encouraged many psychiatrists to adopt a primarily biological view of the genesis of psychiatric illness-often at the expense of psychosocially oriented practice.

Still, there is good news, said Clemens. Surveys conducted by COPP and the American Association of Directors of Psychiatric Residency Training show that the demand for solid psychotherapy training is strong among residents. Better training in short-term, structured and problem-oriented treatments is particularly sought after, since these modalities have been systematically evaluated and, therefore, are more likely to be reimbursed by managed care companies.

Developing Training Programs

The issue of what to teach and how to teach it in the era of managed care, federal health care regulations and effective, new pharmacological agents has been comprehensively examined by Bernard D. Beitman, M.D., professor and chair of the department of psychiatry and neurology at the University of Missouri at Columbia. Beitman, along with colleague Dongmei Yue, M.D., resident at University of Missouri at Columbia and formerly an assistant professor at the department of psychiatry of China Medical University in Sheyang, China, have examined psychotherapy training programs.

"As training programs in psychopharmacology become increasingly more standardized in an effort to provide information in time-efficient ways, training in psychotherapy should also be considered for basic standardization for the same reasons," write Beitman and Yue in an upcoming article (Beitman and Yue, in press). "Psychotherapy is a crucial element of resident education; its generic components are well-established. This program offers a possible answer to the need for a time-efficient training program in the basics of psychotherapy."

Beitman and Yue believe that U.S. residency training programs for psychiatrists lack a systematic, integrated approach that is simultaneously clinically and research-based (Beitman and Yue, in press). For example, most U.S. residency training programs allow instructors and supervisors to present their own perspectives, "implicitly suggesting that trainees should put the ideas and techniques together in a way that suits them personally."

A second increasingly common type of program relies on a manual-based training model. This type of training is effective in presenting a variety of different theoretical perspectives along with the necessary nuts-and-bolts skills, such as the use of cognitive therapy in the treatment of depression. Unfortunately, write Beitman and Yue, "a manual-focused training program limits understanding of other possible approaches for those patients who have more complicated presentations than those addressed by protocol-prescribed approaches."

In response to these concerns, Beitman and Yue have developed a series of training modules that gather core concepts and techniques common to the major psychotherapeutic schools (Beitman and Yue, in press). The goal of the modules is to give residents a solid grounding in psychotherapy basics while requiring them to use established research protocols to sharpen inductive reasoning and to measure their therapeutic competence over the course of their work with patients.

Modules are presented at hour-long seminars held each week over the course of the 12-month program. Residents learn about concepts including, but not limited to, transference, countertransference and resistance. At the same time, residents are required to use a variety of standardized measures that gauge everything from how well they manage therapeutic boundaries to which verbal interventions they use in a given patient interaction. Trainees are also asked to review their answers and explain differences between sets of responses given during each module.

This training technique currently is being used at seven U.S. sites. Moreover, there are plans to implement the modules later this year in Spain, Canada and several additional U.S. locations.